description: The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies.\n\nThe Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
package_name: hl7.fhir.us.ccda
derivation: constraint
name: OperativeNote
type: Composition
elements:
  type:
    short: type
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1'}
    mustSupport: true
    index: 0
  section:
    index: 1
    slicing:
      rules: open
      discriminator:
      - {path: code, type: value}
      min: null
      slices:
        procedure_description_section:
          match:
            code:
              coding:
              - {code: 29554-3, system: 'http://loinc.org'}
          schema:
            label: Procedure Description Section
            short: Procedure Description Section
            mustSupport: true
            _required: true
            index: 38
            elements:
              title: {short: title, index: 39}
              code:
                label: Procedure Description
                short: Procedure Description
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 29554-3, system: 'http://loinc.org'}
                index: 40
              text: {short: This section contains only human readable content, mustSupport: true, index: 41}
            required: [text, title, code]
        complications_section:
          match:
            code:
              coding:
              - {code: 55109-3, system: 'http://loinc.org'}
          schema:
            label: Complications Section
            short: Complications Section
            mustSupport: true
            _required: true
            index: 8
            elements:
              title: {short: title, mustSupport: true, index: 9}
              code:
                label: Complications
                short: Complications
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 55109-3, system: 'http://loinc.org'}
                index: 10
              text: {short: text, mustSupport: true, index: 11}
              entry:
                short: entry
                index: 12
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    complications_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition']
                        index: 13
            required: [text, title, code]
        procedure_disposition_section:
          match:
            code:
              coding:
              - {code: 59775-7, system: 'http://loinc.org'}
          schema:
            label: Procedure Disposition Section
            short: Procedure Disposition Section
            mustSupport: true
            index: 62
            elements:
              title: {short: title, mustSupport: true, index: 63}
              code:
                label: Procedure Disposition
                short: Procedure Disposition
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 59775-7, system: 'http://loinc.org'}
                index: 64
              text: {short: This section contains only human readable content, mustSupport: true, index: 65}
            required: [text, title, code]
        surgical_drains_section:
          match:
            code:
              coding:
              - {code: 11537-8, system: 'http://loinc.org'}
          schema:
            label: Surgical Drains Section
            short: Surgical Drains Section
            mustSupport: true
            index: 76
            elements:
              title: {short: title, mustSupport: true, index: 77}
              code:
                label: Surgical Drains
                short: Surgical Drains
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 11537-8, system: 'http://loinc.org'}
                index: 78
              text: {short: This section contains only human readable content, mustSupport: true, index: 79}
            required: [text, title, code]
        postoperative_diagnosis_section:
          match:
            code:
              coding:
              - {code: 10218-6, system: 'http://loinc.org'}
          schema:
            label: Postoperative Diagnosis Section
            short: Postoperative Diagnosis Section
            mustSupport: true
            _required: true
            index: 34
            elements:
              title: {short: title, mustSupport: true, index: 35}
              code:
                label: Postoperative Diagnosis
                short: Postoperative Diagnosis
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10218-6, system: 'http://loinc.org'}
                index: 36
              text: {short: This section contains only human readable content, mustSupport: true, index: 37}
            required: [text, title, code]
        anesthesia_section:
          match:
            code:
              coding:
              - {code: 59774-0, system: 'http://loinc.org'}
          schema:
            label: Anesthesia Section
            short: Anesthesia Section
            mustSupport: true
            _required: true
            index: 2
            elements:
              title: {short: title, mustSupport: true, index: 3}
              code:
                label: Anesthesia
                short: Anesthesia
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 59774-0, system: 'http://loinc.org'}
                index: 4
              text: {short: text, mustSupport: true, index: 5}
              entry:
                short: entry
                index: 6
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    anesthesia_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/MedicationStatement', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure']
                        index: 7
            required: [text, title, code]
        procedure_findings_section:
          match:
            code:
              coding:
              - {code: 59776-5, system: 'http://loinc.org'}
          schema:
            label: Procedure Findings Section
            short: Procedure Findings Section
            mustSupport: true
            _required: true
            index: 24
            elements:
              title: {short: title, mustSupport: true, index: 25}
              code:
                label: Procedure Findings
                short: Procedure Findings
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 59776-5, system: 'http://loinc.org'}
                index: 26
              text: {short: text, mustSupport: true, index: 27}
              entry:
                short: entry
                index: 28
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    procedure_findings_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition']
                        index: 29
            required: [text, title, code]
        procedure_estimated_blood_loss_section:
          match:
            code:
              coding:
              - {code: 59770-8, system: 'http://loinc.org'}
          schema:
            label: Procedure Estimated Blood Loss Section
            short: Procedure Estimated Blood Loss Section
            mustSupport: true
            _required: true
            index: 20
            elements:
              title: {short: title, mustSupport: true, index: 21}
              code:
                label: Procedure Estimated Blood Loss
                short: Procedure Estimated Blood Loss
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 59770-8, system: 'http://loinc.org'}
                index: 22
              text: {short: This section contains only human readable content, mustSupport: true, index: 23}
            required: [text, title, code]
        plan_of_treatment_section:
          match:
            code:
              coding:
              - {code: 18776-5, system: 'http://loinc.org'}
          schema:
            label: Plan of Treatment Section
            short: Plan of Treatment Section
            mustSupport: true
            index: 50
            elements:
              title: {short: title, mustSupport: true, index: 51}
              code:
                label: Plan of Treatment
                short: Plan of Treatment
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 18776-5, system: 'http://loinc.org'}
                index: 52
              text: {short: text, mustSupport: true, index: 53}
              entry:
                short: entry
                mustSupport: true
                index: 54
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        refers: ['http://hl7.org/fhir/StructureDefinition/Appointment', 'http://hl7.org/fhir/StructureDefinition/Communication', 'http://hl7.org/fhir/StructureDefinition/CommunicationRequest', 'http://hl7.org/fhir/StructureDefinition/DeviceRequest', 'http://hl7.org/fhir/StructureDefinition/NutritionOrder', 'http://hl7.org/fhir/StructureDefinition/RequestGroup', 'http://hl7.org/fhir/StructureDefinition/ServiceRequest', 'http://hl7.org/fhir/StructureDefinition/Task', 'http://hl7.org/fhir/StructureDefinition/VisionPrescription', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest']
                        index: 55
            required: [text, title, code]
        operative_note_surgical_procedure_section:
          match:
            code:
              coding:
              - {code: 10223-6, system: 'http://loinc.org'}
          schema:
            label: Operative Note Surgical Procedure Section
            short: Operative Note Surgical Procedure Section
            mustSupport: true
            index: 42
            elements:
              title: {short: title, mustSupport: true, index: 43}
              code:
                label: Operative Note Surgical Procedure
                short: Operative Note Surgical Procedure
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10223-6, system: 'http://loinc.org'}
                index: 44
              text: {short: This section contains only human readable content, mustSupport: true, index: 45}
            required: [text, title, code]
        preoperative_diagnosis_section:
          match:
            code:
              coding:
              - {code: 10219-4, system: 'http://loinc.org'}
          schema:
            label: Preoperative Diagnosis Section
            short: Preoperative Diagnosis Section
            mustSupport: true
            _required: true
            index: 14
            elements:
              title: {short: title, mustSupport: true, index: 15}
              code:
                label: Preoperative Diagnosis
                short: Preoperative Diagnosis
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10219-4, system: 'http://loinc.org'}
                index: 16
              text: {short: text, mustSupport: true, index: 17}
              entry:
                short: entry
                index: 18
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    preoperative_diagnosis_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition']
                        index: 19
            required: [text, title, code]
        operative_note_fluids_section:
          match:
            code:
              coding:
              - {code: 10216-0, system: 'http://loinc.org'}
          schema:
            label: Operative Note Fluids Section
            short: Operative Note Fluids Section
            mustSupport: true
            index: 46
            elements:
              title: {short: title, mustSupport: true, index: 47}
              code:
                label: Operative Note Fluids
                short: Operative Note Fluids
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10216-0, system: 'http://loinc.org'}
                index: 48
              text: {short: This section contains only human readable content, mustSupport: true, index: 49}
            required: [text, title, code]
        procedure_indications_section:
          match:
            code:
              coding:
              - {code: 59768-2, system: 'http://loinc.org'}
          schema:
            label: Procedure Indications Section
            short: Procedure Indications Section
            mustSupport: true
            index: 66
            elements:
              title: {short: title, mustSupport: true, index: 67}
              code:
                label: Procedure Indications
                short: Procedure Indications
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 59768-2, system: 'http://loinc.org'}
                index: 68
              text: {short: This section contains only human readable content, mustSupport: true, index: 69}
              entry:
                short: entry
                index: 70
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    problem_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition']
                        index: 71
            required: [text, title, code]
        procedure_specimens_taken_section:
          match:
            code:
              coding:
              - {code: 59773-2, system: 'http://loinc.org'}
          schema:
            label: Procedure Specimens Taken Section
            short: Procedure Specimens Taken Section
            mustSupport: true
            _required: true
            index: 30
            elements:
              title: {short: title, mustSupport: true, index: 31}
              code:
                label: Procedure Specimens Taken
                short: Procedure Specimens Taken
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 59773-2, system: 'http://loinc.org'}
                index: 32
              text: {short: This section contains only human readable content, mustSupport: true, index: 33}
            required: [text, title, code]
        planned_procedure_section:
          match:
            code:
              coding:
              - {code: 59772-4, system: 'http://loinc.org'}
          schema:
            label: Planned Procedure Section
            short: Planned Procedure Section
            mustSupport: true
            index: 56
            elements:
              title: {short: title, mustSupport: true, index: 57}
              code:
                label: Planned Procedure
                short: Planned Procedure
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 59772-4, system: 'http://loinc.org'}
                index: 58
              text: {short: text, mustSupport: true, index: 59}
              entry:
                short: entry
                index: 60
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    planned_procedure_entry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/ServiceRequest']
                        index: 61
            required: [text, title, code]
        procedure_implants_section:
          match:
            code:
              coding:
              - {code: 59771-6, system: 'http://loinc.org'}
          schema:
            label: Procedure Implants Section
            short: Procedure Implants Section
            mustSupport: true
            index: 72
            elements:
              title: {short: title, mustSupport: true, index: 73}
              code:
                label: Procedure Implants
                short: Procedure Implants
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 59771-6, system: 'http://loinc.org'}
                index: 74
              text: {short: This section contains only human readable content, mustSupport: true, index: 75}
            required: [text, title, code]
package_version: 1.2.0-ballot
class: profile
kind: resource
url: http://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note
base: http://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header
version: 1.2.0-ballot